I'm a Visiting Professor at Cardozo Law School where my research focuses on media law with a particular focus on law and social media. Previously, I was the Editorial Counsel for Forbes magazine and Forbes.com. E-mail me at kai.falkenberg@yu.edu.

Why Rating Your Doctor Is Bad For Your Health

SUFFERING FROM A TOOTHACHE, a South Carolina woman headed to her local emergency room a few months ago. The doctor there responded by administering Dilaudid, a powerful intramuscular narcotic typically reserved for cancer-related pain. Why, his nurse queried, was he killing a flea with a sledgehammer? Afraid of malpractice? No, the doc replied, Press Ganey. “My scores last month were low.”

Press who? The little-known company has become a hated target of hospital physicians, outstripping even trial lawyers. Utter its name in an emergency room and you’ll likely unleash a cloud of four-letter words. Based in South Bend, Ind., Press Ganey is the nation’s leading provider of patient satisfaction surveys, the Yelp equivalent for hospitals and doctors, and a central component of health care reform. Over the past decade the government has fully embraced the “patient is always right” model–these surveys focus on areas like waiting times, pain management and communication skills–betting that increased customer satisfaction will improve the quality of care and reduce costs. There’s some evidence they have. An ObamaCare initiative adds extra teeth, to the tune of $850 million, reducing Medicare reimbursement fees for hospitals with less-than-stellar scores.

Catering to Patients Can Be Harmful to Their Health

Accordingly, hospitals kowtow to Press Ganey. In November nearly 2,000 administrators spent $1,100 or more each to attend Press Ganey’s glittery client conference–a closed-to-the-public affair in Washington, D.C., with keynotes by Jeb Bush and astronaut Mark Kelly and his wife, former congresswoman Gabby Giffords. Press Ganey is helping hospitals fulfill their mandated obligation. Some have taken an extra step, tying physicians’ compensation to their ratings.

That may sound like a good thing. Why shouldn’t you grade the quality of your medical care, the way that you pass judgments on other services, whether hotel stays via TripAdvisor or contractors via Angie’s List?

The short reason: The current system might just kill you. Many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to “satisfy” patients, who probably aren’t qualified to judge their care. And there’s a financial cost, as flawed survey methods and the decisions they induce, produce billions more in waste. It’s a case of good intentions gone badly awry–and it’s only getting worse.

FOR ALL THE DOCTORS OUT THERE CARPING about these surveys, a message from Press Ganey CEO Patrick Ryan, a veteran health care executive: Suck it up. “Nobody wants to be evaluated; it’s a tough thing to see a bad score,” he says. “But when I meet with physician groups I tell them the train has left the station. Measurement is going to occur.”

But what exactly are Press Ganey and its two main rivals, the Gallup polling company and the publicly traded National Research Corp., measuring? Customers know what they want when they review spaghetti carbonara for Zagat. But giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine. Last February researchers at UC Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on health care and prescription drugs. They were 12% more likely to be admitted to the hospital and accounted for 9% more in total health care costs. Strikingly, they were also the ones more likely to die.

Why? The UC Davis authors posit that the most satisfied patients have a higher mortality rate because they receive more discretionary services–interventions that carry a risk of adverse effects. Even routine screenings for diseases like prostate cancer can lead to unnecessary drugs and operations with allergic reactions and surgical complications that leave patients worse off. (While the report controlled for age and health status, critics have challenged its methodology and claimed its findings are overstated. But other studies also confirm that patient satisfaction is not always a reliable index of good care.)

“Numerous studies have found that patients are consistently highly satisfied with one of the most common downsides of medical care–false-positive test results and the downstream events that follow,” wrote Dr. Brenda Sirovich of the VA Outcomes Group in White River Junction, Vt., commenting on the UC Davis study. “Almost any unnecessary or discretionary test has a good chance of detecting an abnormality.” Such testing “is a double-edged sword,” explains Dr. H. Gilbert Welch in his 2011 book, Overdiagnosed, often leading to “the detection of abnormalities that are not destined to ever bother us.”

Our health care system already suffers from a “more is always better” fallacy. “Practicing physicians have learned–from reimbursement systems, the medical liability environment and clinical performance scorekeepers–that they will be rewarded for excess and penalized if they risk not doing enough,” says Sirovich. An overreliance on patient surveys, she says, only inflames the problem of overtreatment.

Press Ganey’s Ryan points the finger elsewhere: “If there’s anything going on that’s driving somebody to test more, it’s the fear of malpractice.” For the past few decades that’s certainly been true. Money drives professional behavior for doctors, as it does for virtually everyone else, and the soaring insurance premiums that come with a malpractice suit have surely affected decision making.

But as hospitals and other employers increasingly tie physicians’ compensation to patient wishes, doctors are pushed even further down the dangerous path of overtreatment. Nearly two-thirds of all physicians now have annual incentive plans, according to the Hay Group, a Philadelphia-based management consultancy that surveyed 182 health care groups. Of those, 66% rely on patient satisfaction to measure physician performance; that number has increased 23% over the past two years.

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Ms. Falkenberg’s article succeeds in drawing attention to an issue in health policy that clearly deserves it. She makes numerous excellent points about how “customer satisfaction” in health care is not quite the same as in other areas of our consumer-oriented economy. Relabeling what is being measured as the “patient experience” rather than “customer satisfaction” does not change the fact that we don’t really know what we’re measuring, or how to measure it, or that we measure it poorly because of flawed methodology and inadequate sampling. Most worrisome is that the Centers for Medicare and Medicaid Services has decided to punish hospitals that don’t do well on these surveys, and the poor performers tend to be the hospitals at greatest risk for serious financial harm from this treatment. Congratulations to the author for shedding light on a complex subject. Many physicians have written about this (see, for example, http://bobsolomon.blogspot.com/2012/06/keep-customer-satisfied.html) but are handicapped by Press-Ganey’s ad hominem implication that they are just whiners because they don’t like being judged. Ms. Falkenberg’s impartial perspective is most welcome.

Kai: I was pleased to see your excellent article finally available on the web. I had read it in the Forbes magazine before it was on your blog. This piece is consistent with what my colleagues and I had been advised at our hospital staff meetings: these patient satisfaction surveys are important to the hospital bottom line. I was unaware of any ties to physician compensation, at least at our institution. This effort by CMS and the feds is just one of one many steps that are destroying the physician patient relationship. The billions taken from taxpayers doled out to hospitals via crony capitalism to implement electronic medical records is another destructive measure. The data and evidence suggest that all these efforts lead to worse care not better, despite the big government lies, oft repeated.

We continue to discuss this topic over and over. Truth be told, the data is flawed and the system of collection. Until we move forward as an industry in patient satisfaction/experience data collection from the Stone Age of paper/IVR to cloud/tablet real time data collection and reporting we will always be asking these types of questions.

The problem is, no one is talking about the real issue and/or no one wants to address it… My team and I have.

Here is a little post I wrote entitled, “The Elephant In The Room” http://www.patientexperience.us/thoughts-insight-and-news.html

Connect with me on LI. We are ready to lead change in an area that is in such desperate need of change.

I am tired of hearing the PG name used as a scare tactic when the reported return rate for HCAHPS continues to drop (now at 32%).

As a stats guy I see NO relevance from any database where I receive a mere 32% return… in this or any industry!

It is time to get back to serving the patient and not scaring our doctors into padding the PG scores. When in fact the flawed, untimely, overpriced reports we are receiving will do nothing to offer a true reflection of our satisfied patients OR offer any real opportunity to improve their patient care.

So I have a great idea… lets use this data now to reward or discipline our hospitals financially at 30%… this all makes a bunch of sense to me.

I am an emergency physician in NY. Press-Ganey surveys are extremely frustrating because they have been elevated to the level of accurate scientific research when they are not. Everyone who is discharged from my hospital’s ER gets a Press-Ganey survey in the mail, regardless of diagnosis, appropriateness of the ER visit, drug seeking behavior, intoxication, etc. While I have not changed my behavior personally (other than trying to be friendlier and checking on patients more frequently – which is a good thing), there is definitely pressure to prescribe and get good scores given the pay-for-performance incentives. I just have an incredibly hard time understanding why the government would judge me on the basis of only a few surveys which may or may not have been filled out by persons who visited six ERs in three weeks for Percocet prescriptions. The callous response from Press-Ganey is reflective of the problem: they can’t provide accurate data, and yet they claim they are measuring our performance? That’s preposterous. But we can expect nothing more of a government that feels physicians can’t meaningfully contribute to any decisions on how healthcare is provided, and that regularly vilifies us as “rich doctors” who perform “too many tests,” “send patients home too soon,” and “give you hospital-based infections.”

The other thing I neglected to mention – equally important – is that I am female and look young for my age. I always clearly introduce myself when I enter a room. Many, many, many times I will have been caring for a patient for many hours – often at the bedside, for critically ill patients – and the patient and family will call the nurse manager into the room, angry that the physician never saw them or cared for them. Sometimes this happens shortly after I conclude a long (>10 min) discussion about their condition and their plan. I am sure I bomb on those Press-Ganey scores, but there’s really nothing I can do to fight perception and bias. And yes, those surveys count against me, too. Even if, in spite of explanation, they never figure out that the “girl” was the “doctor.”

LOL, I am so glad I’m not the only MD with this problem. I’m an oncologist and would have these long, painful, deep conversation with patient and family (at least 20-30 minutes, frequently around an hour) and it’s not uncommon for the family to conclude the conversation by saying “thank you Miss for caring, let’s see what the Doctor say”. They usually believe I’m a social worker, a student, a nurse (one family said since I’m wearing a white coat I must be a head nurse — a PROMOTION! LOL) or an administrator. I work for an HMO that send patient satisfaction answers to everyone (outpatient and inpatient) so it’s been interesting to see my patient scores.

Another ER doc here… I’ve personally never felt terribly troubled by my Press Ganey scores as the n= 5-10 patients quarterly despite the fact I worked 1400 hrs that year and saw an average of 2.7 patients an hour. It can be hard to read that I might have been quick, dismissive or even rude to patients and I’ve tried to improve my bedside manner based on past Press Ganey comments from my patients. The reality is there are many shifts when we haven’t eaten or urinated and that feedback was the ankle sprain that got squeezed in between ICU transfers, laceration repairs, grieving families, psychotic patients, etc etc (It’s no wonder ED physicians have lower scores compared to other hospital units that have more control over patient volume, acuity and staffing). What Press Ganey does recommend to administrators of hospitals is to do “leadership rounding” when they are at their overpriced Press-Ganey boot camp seminars. This would involve hospital leadership actually talking to patients and staff (in real time) about their experiences in the department. In any event, it is not a bad thing to remind hospital administrators that our patient’s experiences are helpful when developing updates to hospital operations. In fact, it is well shown that patient satisfaction is directly correlated to length of patient stay. The ED overcrowding issues (related to unavailable hospital beds) likely have more to do with dismal rates of satisfaction than how many narcotic scripts I write for my patients. Ahh, but then there really are the patients to consider in this discussion. Without shared electronic medical records between hospitals, it is all so duplicitous, frustrating and inefficient. How would I know that my patient really came to the ER for presumed miscarriage with her boyfriend so he might not suspect she just had an elective abortion but wanted him to think it was a spontaneous event? How would I know the patient who alleges a new symptom just had a full work-up at an outside hospital but doesn’t believe the diagnosis and consents to another CT scan of the chest with contrast putting him at great risk for acute kidney failure? How would I know the psych patient in room two just “bounced” from an inpatient stay, never got his meds filled, has escalating feelings of homicidality and a gangbanger brother with an assault weapon at the house? These are not fictitious cases… I hope to see more discussions which address core deficits in our healthcare system.